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GERIATRIC FAILURE TO THRIVE

Abstract

Geriatric failure to thrive may be caused by a single, medical condition but in most cases, there are multiple issues, some treatable and some not. Identifying this syndrome is challenging and often clinicians will confuse failure to thrive with the normal aging process. However, they are very different conditions and its critical for failure to thrive to be appropriately diagnosed for a correct prognosis and treatment to be determined. The hallmarks of geriatric failure to thrive are cognitive impairment, depression, impaired physical functioning, and malnutrition. Treatment is individualized and a multi-disciplinary team approach provides the best chance for success.

Learning Goal:

1. Identify key risk factors of geriatric failure to thrive

2. Describe physical symptoms of an elderly person with failure to

thrive.

3. Describe types of treatment available for an elderly person

diagnosed with failure to thrive.

4. Provide an example of a condition that might not be responsive to

medical and supportive treatment in a case of geriatric failure to thrive.

5. Describe the difference between normal aging and failure to thrive.

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Introduction

Geriatric failure to thrive is a complex condition in the elderly that is caused by physical and psychological impairments that slowly decrease an individual's functional abilities over time. Some clinicians confuse geriatric failure to thrive with the normal aging process; however, it is not the same condition. An elderly person who has geriatric failure to thrive is functioning at levels far below what is expected given the person's capabilities. Certified Nursing Assistants (CNAs) and Health Aides need to understand the key identifying feature of geriatric failure to thrive. They should be informed about the causes, signs and symptoms, and treatment of geriatric failure to thrive.

National Statistics

Geriatric failure to thrive is a complex condition that affects millions of the elderly. This condition has also been called failure to thrive in the elderly and adult failure to thrive. These refer to the same concern. It is caused by physical and psychological impairments that over time, slowly decrease an individual's functional abilities. Functional abilities, which are essentially the capacity to perform self-care and maintain a vigorous state of mind, are the skills that keep individuals healthy and happy and when they are lost then a decline begins and failure to thrive occurs. People who suffer from geriatric failure to thrive will often complain that they "just don't feel like themselves," and family members will observe that their relative "doesn't seem the same." Failure to thrive in a given population depends on certain risks. Elderly living in low income settings, exposed to infectious diseases, poverty, victims of elder abuse and neglect, and inadequate nutrition are primarily at risk. Higher rates of geriatric failure to thrive has reported cnazone.com cnazone.com cnazone.com cnazone.com cnazone.com 3 to occur in economically disadvantaged rural and urban areas. In the United States, there can be a myriad of causes, which are discussed in the following sections. Because failure to thrive is a syndrome that happens to the elderly, it is easily mistaken for physical and mental decline associated with the aging process. This is particularly evident in countries like the U.S., with growing elderly populations, and the increase of elderly people living in long-term care facilities. However, geriatric failure to thrive is not normal. An older person may have chronic illnesses and may have lost a degree of mental acuity but most people can cope with these challenges. A patient who has geriatric failure to thrive is functioning at levels far below what is expected or usual for a patient of similar age and condition. Patients report that they "don't feel like themselves," and their relatives notice that the patient "doesn't seem the same." Geriatric failure to thrive is most often caused by multiple and inter- related issues, each of which may be a serious condition by itself. Recognizing geriatric failure to thrive is important because there are effective interventions for many of these issues that may be used if a diagnosis is made. Definition and Causes of Geriatric Failure to Thrive The simplest definition of geriatric failure to thrive is functional decline. Someone who has geriatric failure to thrive is not functioning, physically, emotionally, and psychologically, at the level that would be expected for them. cnazone.com cnazone.com cnazone.com cnazone.com cnazone.com 4 There are some important questions and several crucial issues to address related to geriatric failure to thrive. Firstly, functioning and thriving are general terms. In the context of geriatric failure to thrive, functioning describes actions that contribute to maintaining physical and psychological health. To thrive means that a person is doing as well as would be expected in the areas of life, given the person's age and condition. The difference between the normal decline of abilities and functioning that accompanies aging and the functional losses seen in geriatric failure to thrive needs to be understood. It is the failure to thrive that is the key component of the syndrome. If someone's functional ability has declined and there is no ability to compensate for this, a failure to thrive will happen. Geriatric failure to thrive is not about a person's level of functional ability; it is about how much a person's functional ability affects day- to-day life, the quality of life, and how well a person is coping. This is well-illustrated by the International Classification of Diseases (ICD) description of adult failure to thrive. The ICD is a system of codes that is used to standardize the diagnosis and identification of diseases and medical-surgical conditions. The ICD recognizes a condition that it calls adult failure to thrive, and part of the ICD definition of this condition is: "The individual's ability to live with multisystem diseases, cope with ensuing problems, and manage his/her care are remarkably diminished." People suffer some level of physical and psychological decline as they get older. What caregivers need to understand is how much a person's functional abilities must decline to constitute geriatric failure to thrive. cnazone.com cnazone.com cnazone.com cnazone.com cnazone.com 5 It is true that everyone's functional abilities decline as they age but geriatric failure to thrive results from definite causes such as a chronic medical disease or dementia; it is not simply the condition of "getting old." Also, a diagnosis of geriatric failure to thrive is made after a careful, organized evaluation of a patient's ability to perform activities of daily living, ambulatory status, cognitive abilities, mood, and other functional categories. If there are significant deficits, the diagnosis is confirmed. Someone who has geriatric failure to thrive is not functioning physically, emotionally, and psychologically at the level that would be expected. Geriatric failure to thrive is not a result of the normal aging process. It is important to maintain the perspective that geriatric failure to thrive is caused by medical and psychological conditions that affect someone's physical and mental ability to function.

Elderly Patient Profile of Failure to Thrive

It was mentioned in the introduction that people who suffer from geriatric failure to thrive will often complain of not feeling like themselves, or that family members may notice a disturbing difference in their relative's condition. These impressions, although they are subjective, are insightful and they illustrate important points - the patient's condition has changed and he or she is not doing as well as would be expected. Of course, when someone is ill or, to a lesser degree, when someone is going through the aging process, these types of complaints and observations are common. The importance of functional decline was covered previously and is key to recognizing the syndrome of geriatric failure to thrive, especially the fact that the patient is not functioning as well as would be expected. cnazone.com cnazone.com cnazone.com cnazone.com cnazone.com 6 Patients with geriatric failure to thrive often seem indifferent and depressed. They may have little interest in activities they previously enjoyed and they do not care to socialize. Eating is a low priority and the patient no longer prepares meals. Instead, the patient eats irregularly or snacks on what is at hand. As a result, the patient loses a noticeable amount of weight. The patient's level of physical activity dramatically decreases because of a lack of energy and because the patient's physical abilities have declined. Finally, a patient who has geriatric failure to thrive has a definite impairment in intellectual ability. This may be evident in minor details, such as the patient has difficulty in performing a simple task or remembering a telephone number; or it may be evident in more serious ways, such as the patient becomes disoriented and does not know the year, the month, or the day of the week, or is incapable of looking up a new telephone number and dialing it.

Causes of Failure to Thrive

Geriatric failure to thrive may be due to a single disease or condition but most cases of this syndrome are multi-factorial in origin. There are many medical conditions that can contribute to geriatric failure to thrive and quite often someone who has this syndrome will have several physical and psychological pathologies that are part of the clinical picture. A helpful way of categorizing and remembering the basic causes of geriatric failure to thrive is the phrase, the 11 Ds. This list was first cnazone.com cnazone.com cnazone.com cnazone.com cnazone.com 7 complied many years previously and collectively these are called, for obvious reasons, The Dwindles.

The 11 Ds of the Dwindles

Diseases, i.e., medical illnesses

Dementia

Delirium

Drinking alcohol and other substance use

Drugs

Dysphagia

Deafness, blindness, and other sensory deficits

Depression

Desertion by family, friends

Destitution

Despair

The 11 Ds provide a useful starting point for determining the possible reasons why some have geriatric failure to thrive. For each reason, there are multiple possibilities. Dementia can be caused by Alzheimer's disease, a cerebrovascular accident (commonly called a stroke), Parkinson's disease, and other medical conditions. These conditions negatively impact a person's cognitive ability and functional ability. Drugs such as sedatives, for example diazepam (brand name of Valium) and antipsychotics, for example haloperidol (brand name Haldol) can cause confusion, drowsiness, and difficulty ambulating. Someone who is confused, drowsy, and may not walk safely, cannot function independently. Also, depression is often present in people who cnazone.com cnazone.com cnazone.com cnazone.com cnazone.com 8 have geriatric failure to thrive. People who are depressed often have a lack of appetite, they withdraw socially, and they may be apathetic about self-care, all of which can contribute to failure to thrive.

Identifying Failure to Thrive

Identifying geriatric failure to thrive is difficult. There are the 11 Ds of the dwindles as mentioned previously, and for each one there are multiple possibilities and their presence does not necessarily identify someone who has geriatric failure to thrive. However, there are four conditions that are commonly seen in patients who have geriatric failure to thrive and the presence of these strongly suggest its presence: 1) cognitive impairment, 2) depression, 3) impaired physical function, and 4) malnutrition. Because these are such an important part of geriatric failure to thrive they will be covered at length, including the assessment or screening tools used for detecting these syndromes. The assessment or screening tools are administered by nutritionists, primary care physicians, psychologists, gerontologists, and physical therapists who are experienced in working with the elderly and assessing for failure to thrive conditions. It is not necessary that a caregiver memorize the conditions; they are included here to provide examples of the signs and symptoms and functional declines that characterize geriatric failure to thrive. The complete process of evaluating an elderly person for the presence of geriatric failure to thrive will be covered in the following sections.

Cognitive Impairment

cnazone.com cnazone.com cnazone.com cnazone.com cnazone.com 9 The word cognitive means of or relating to consciousness and intellectual ability. Cognitive impairment is a change, a noticeable change for the worse, in someone's ability to think, reason, make judgments, remember, and plan. Everyone loses some degree of mental ability and memory as they age but for the person who has geriatric failure to thrive, the cognitive deficits are greater than what is expected and these deficits negatively affect functioning. There are many medical conditions that can cause cognitive impairment in the elderly: Alzheimer's disease, cerebrovascular accident (stroke), Parkinson's disease, infections, medication adverse effects and dehydration are some of the more common ones. Screening tests that can be used for detecting cognitive impairment are easily available, and each one has specific uses. The Mini-Mental State Examination and the Mini-Cog test are briefly discussed here.

Mini-Mental State Examination

The Mini-Mental State Examination assesses important aspects of cognitive ability, including the individual's orientation, attention, calculating ability, recall, and language skills. There are 30 questions: a correct answer scores one point and a score of less than 20 usually indicates cognitive impairment. The Mini-Mental State Examination is a screening test only; it can detect cognitive impairment but it cannot determine what is causing it. The other limitation of the Mini-Mental State Examination is that it depends to a large degree on verbal response and reading and writing skills. If there is a language barrier or the person being tested cannot read or write or cannot do either well, the test results would be skewed. cnazone.com cnazone.com cnazone.com cnazone.com cnazone.com 10 Examples of Mini-Mental State Examination questions are provided below. The questions are very simple and difficulty in answering them correctly will clearly demonstrate cognitive impairment.

Mini-Mental State Examination Questions

Orientation:

To determine a person's level of orientation, the examiner will ask: What is the year, the month, the day of the week, and the season?

Language Skills:

Show the individual a wristwatch and it to be identified. Repeat the same exercise, using a pencil.

Recall:

Ask the individual to repeat the following words: "No ifs, ands, or buts," and ask for the words to be repeated after 3 minutes.

Attention and Calculating Ability:

Ask the individual to spell 'WORLD' forward and backward. Alternatively, ask the individual to start at 100 and count backwards in intervals of 7. Stop after five correct repetitions, i.e., after the number 65.

Mini-Cog

The Mini-Cog test is similar to the Mini-Mental State Examination but it is shorter and takes less time to administer. The Mini-Cog test has three parts: 1) word recognition and short-term memory, 2) the ability to draw a simple picture of a clock, draw in the hours, and then put the hands of the clock at specified time, and 3) recall of the words that cnazone.com cnazone.com cnazone.com cnazone.com cnazone.com 11 were used in part 1 of the test. Taken together these three parts of the Mini-Cog can detect deficits in memory, language, and motor skills. The Mini-Cog is a trademarked product and cannot be reproduced without permission but interested readers can see it by accessing this website address: http://mini-cog.com/.

Depression

Depression is the most common psychiatric disorder in the elderly and depression, defined simply as a persistent depressed mood accompanied by impaired functioning, can be both a contributing cause of geriatric failure to thrive and a consequence of this syndrome. For example, depression can contribute to geriatric failure to thrive by causing lack of appetite, leading to weight loss and a decrease in strength, increasing the risk for falling, and by causing insomnia. As a consequence of geriatric failure to thrive, depression leads to a decline in functioning, which further results in a loss of independence, possibly social isolation, and diminished hope for the future. Some of the risk factors for depression in the elderly are listed below.quotesdbs_dbs14.pdfusesText_20

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